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HomeMy WebLinkAboutNCS000166_Owner Affiliation Designation_20200330Division of Energy, Mineral, and Land Resources Land Quality Section / Stormwater Program - National Pollutant Discharge Elimination System (NPDES) Energy' Mineral` PERMIT OWNER AFFILIATION DESIGNATION FORM Land Resources ENVIRONMENTAL OUALITY (Individual Legally Responsible for Permit) Use this form if there has been: FOR AGENCY USE ONLY Date Received Year Month Day NO CHANGE in facility ownership or facility name, but the individual who is legally responsible for the permit has changed. If the name of the facility has changed, or if the ownership of the facility has changed, do NOT use this form. Instead, you must fill out a Name -Ownership Change Form and submit the completed form with all required documentation. What does "legally responsible individual" mean? The person is either: RECEIVED • the responsible corporate officer (for a corporation); " X • the principle executive officer or ranking elected official (for a municipality, stafe,edera er public ffi agency); DENR-LAND QUAI_IT`( • the general partner or proprietor (for a partnership or sole proprietorship); STORM NATER FERIA 1117ING • or, the duly authorized representative of one of the above. 1) Enter the permit number for which this change in Legally Responsible Individual ("Owner Affiliation") applies: Individual Permit N I C I S O 0 10 11 16 16 2) Facility Information: Facility name: Company/Owner Organization: Facility address: (or) Certificate of Coverage or No Exposure N C G Lewiston Mill Perdue Foods, LLC 3539 Governors Rd Address Lewiston NC 27849 City State Zip To find the current legally responsible person associated with your permit, go to this website: https://deg.nc.gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permits/npdes-industrial- rp ogram and run the Permit Contact Summary Report. 3) OLD OWNER AFFILIATION that should be removed: Previous legally responsible individual: Wayne First MI 4) NEW OWNER AFFILIATION (legally responsible for the permit): Person legally responsible for this permit: Jeff First MI Black Last Stalls Last Page I of 2 S WU-OWNERAFFIL4Nov2019 NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION Form (if no Facility Name/Ownership Change) Director of Operations Title PO Box 460 Mailing Address Lewiston NC 27849 City State Zip (252 ) 348-4271 jeff.staIls@perdue.corn Telephone E-mail Address (410 ) 341-8058 Fax Number 5) Reason for this change: ❑✓ Employee or management change A result of: Inappropriate or incorrect designation before ❑ Other If other please explain: The certification below must be completed and signed by the permit holder. PERMITTEE CERTIFICATION: I Kyle Bolin , attest that this application for this change in Owner Affiliation (person legally responsible for the permit) has been reviewed and is accurate and complete to the best of my knowledge. I understand that if all required parts of this form are not completed, this change may not be processed. Signature Date PLEASE SEND THE COMPLETED FORM TO: DEMLR - Stormwater Program Dept. of Environmental Quality 1612 Mail Service Center Raleigh, North Carolina 27699-1612 For more information or staff contacts, please call (919) 707-9220 or visit the website at: http://deg.nc.gov/about/divisions/energy-mineral-land-resources/stoirnwater Page 2 of 2 S WU-O WNERAFFIL-4Nov2019 November 14, 2019 Wastewater Branch Water Quality Permitting Section Division of Water Resources 1617 Mail Service Center Raleigh, NC 27699-1617 Subject: Delegation of Signature Authority PERDUE FOODS, LLC NPDES Permit Number NCS000166 To Whom It May Concern: By notice of this letter, I hereby delegate signatory authority to each of the following individuals for all permit applications, discharge monitoring reports, and other information relating to the operations at the subject facility as required by all applicable federal, state, and local environmental agencies specifically with the requirements for signatory authority as specified in 15A NCAC 213.0506. Individual 41 Individual #2 (if applicable) Marne: Jeff Stalls Title: Director Of Operations Mailing Address: ! Po Box 460 Lewiston, Nc 27849 Physical Address: (f d fferent) 3539 Governors Rd Lewiston, Nc 27849 Email Address: jef£stalls@perdue.com Office Phone: 252 - 348 - 4271 - - Mobile Phone: 252 - 209 - 4178 - - If you have any questions regarding this letter, please feel free to contact me at 410-543-3227 or kyle.bolin@perdue.com. Sincerely, Kyle Bolin Vice President Of Operations 31149 Old Ocean City Rd, Salisbury, MD 21804 Kyle.Bolin@Perdue.Com 410-543-3227 cc: Washington Regional Office, Water Quality Permitting Section